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Yr APPLICATION FOR SANITATION PERMIT Permit No. _A1 (Complete in Duplicate) Date Issued _____ Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and inst 1 the work herein.described. This application is made in compliance with County Ordinance No. 549. ovuYeu-110-�1 211 _ JOB ADDRESS AND LOCATION__--_ �_ JS.c. 0 Owner's Name -------- - ------------------------------------------ Phone--------------Address--- ---•2------1e_ -----_1 y a E/5� t�._-[? Contractor's Name--- fhone__Y` 06"26 lr- ----------------------------------------------------- Installation will serve: Residence V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � Number of living units: __ _____ Number of bedrooms __k Number of baths Lot size ----�(pDe ___--_--------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table .3Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E-1SandyLoam ❑ Clay Loam [jClay ❑. ,Adobe ' Hardpan ❑ ,S} Previous Application Made: Yes ❑ No (';If' New Construction: Yes ; No E] ♦t TYPE OF INSTALLATION AND SPECIFICATIONS: ,' N (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well �A� Distance from foundation ------- .Material-____________________________ No, of compartments-------3-----.____--__Size +6~ x�'�X 4" -fir Liquid depthy .___--- Capacity. �-- # - Disposal Field: Distance from nearest well/ai.._ _-_Distance from foundation---3QDistance to nearest lot line_,-4______.._ Number of lines---__-Z--------------- Length of each line___'7,S -_-_-N __--_.Width of trench-_____-kv_"----__________ Type of filter material_.�_t-R _Depth of-filter material----L _______.-_-_Total length________�5+,------------------ Seepage Pit: Distance to nearest wellJ06___Vr------Distance from fo ndaticn_-__7r__.__-_.D/�istant a to nearest lot line--- XX Number of pits-----Z-------------Lining material-- Diameter----F1.._5.�.___-------Depth---- Cesspool: Distance from nearest well-----------------Distance from foundation------------- __--,Lining material------------------------------------- C1 Size: Diameter--------------------- --------- ------Depth------------------------------ ---------------------Liquid. Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------------------------------------ 4 ❑ Distance to nearest lot line - Remodeling and/or repairing (describe):--------- --------- --------------------•------------------•--------------------------•---------------- --•-----------------------•------------------------••-•---------------------------------•---------------•---•------------------------------•-------------------------------------------------------------------------------- ----------•-------------- ---------- ---------•--------- -----------------------------•-•----------------------------------------------------------------------------------------------------------------------•--- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stafp laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------ -------- ---•--•- 19------ --------------------------------------------- --------(Owner and/or Contractor) By:------- � ------------------ -----------------------------------------(Title)--------------------------------------------- ----------------- (Plot plan, showing size of lot, locatia f system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - DATE-- -------------•----------•---------------------------- REVIEWEDBY---------------- - ------------------ ---------------------- ---------------------------------- DATE--- BUILDING PERMIT ISSUED--------------------------------------•------------------------------------------------------------- DATE---------- ----------- Alterations and/or recommendations: ----------------- ---------- ---- --- ----•---------------•-------------------------- ---------••----------- -----•-•-------- •------- ----------------------------------------------------------------------------- -------------------------------------------------------------------------------•-------------------------------------------------------I...... -------------------------------------- -----------------------•------•------ -------------------- ---------------------•-------------------- ---------------------------------•-------•--------------------------•---------••_ FINAL INSPECTION BY:--------------------- 1-/�� r,�/ .F), — 7 -�j ------ Date-------------------------- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M : Revised W-2100